MNA M osby ’ s Long Term Care Assistant Chapter 6 Communicating with the Health Team

1. MNAMosby’s Long Term Care AssistantChapter 6 Communicating with the Health Team

2. COMMUNICATION THE EXCHANGE OF INFORMATION • Use words that mean the same thing • Use familiar words • Be brief and concise • Give info in a logical and orderly manner • Give facts and be specific

3. COMMUNICATION OPPORTUNITYISNOWHERE

4. COMMUNICATION Visiting relatives can be a hassle.

5. COMMUNICATION You are temporarily in charge of the pump that keeps everybody on earth alive. The guy who has run it for 62 years suddenly had to leave. The only directions he left were as follows: • Pump needs water to function properly. • You can’t add too much water.

6. The Medical Record - Chart A written account of a patient's condition and response to care and tx

7. The Medical Record - Chart • Permanent • Legal document • Belongs to the HCF • Confidential

8. The Medical Record - Chart • Admission sheet • PE • Doctor’s orders • Doctor’s progress notes • Graphics or Flow Sheets - ADLs

9. The Medical Record - Chart • Lab results • X-ray reports • IV Therapy • RT records • Consultations • Nurses notes

10. The Medical Record - Chart • Kardex: • Summarizes patient’s chart • Quick, easy source of info

11. Kardex Examples

12. Reporting and Recording • Reporting • Oral • To the nurse • Accurate • Name and Room # • Only what you observed or did • Report matters of concern immediately • End of shift

13. Reporting and Recording • Recording • Use ink • Date and Time (Military Time?) • Approved abbreviations • Never erase • Never skip lines • Legible, neat

14. Reporting and Recording • Recording • Correct punctuation, spelling, grammar • Right chart • Never chart a tx until after it is given • Logical sequential • Safety measures • Patients own words if possible

15. Reporting and Recording Errors Error ep pt complains of pain

16. 24 hour clock 24 23 13 22 14 21 15 16 20 17 19 18

17. 8:30 am? 24 hour clock 0830 24 23 13 22 14 21 15 16 20 17 19 18

18. 10:30 am? 24 hour clock 1030 24 23 13 22 14 21 15 16 20 17 19 18

19. 7:30 pm? 24 hour clock 1930 24 23 13 22 14 21 15 16 20 17 19 18

20. 4:00 pm? 24 hour clock 1600

21. 9:00 pm? 24 hour clock 2100

22. midnight? 24 hour clock 2400

23. 12 noon? 24 hour clock 1200

24. 5 minutes after midnight? 24 hour clock 0005

25. Medical terms and abbreviations Word elements • Prefix • Root • suffix

26. prefixes: pg 68 Hyper hypo Mal Olig Per Poly A, an Ab Bi Brady Dys Hemi Post Pre Sub tachy

27. Roots: pg 68 Arthr Cardi Crani Cyan Derma Gastra Hemat hepat Mamm Mast Necro Nephra Orth Therm

28. suffixes: pg 69 Oma Phasia Plegia Ostomy Osis Algia Ectomy Itis Megaly

29. Let’s practice mastectomy dermatitis cyanosis bradycardia

30. Let’s practice hematoma gastrostomy nephramegaly arthroalgia

31. Abbreviations inside back cover Ac ADL Ad lib Am Amb Bid BM B/P BRP C CA CBR cc C/O D/C DON Dx Hr H2O HS Ht I&O

32. Abbreviations LLQ LUQ ml NPO O2 OOB oz Pc Pm Po Prn Pt PT q Qd Qh Q2h Qhs Qid Qod R RLQ

33. Abbreviations ROM RUQ SOB S SSE STAT tid TPR U/A V/S W/c wt

34. Abbreviations Times Qd q2h pc Bid qhs hr Tid hs prn Qid am stat Qod pm Qh ac

35. Abbreviations Activity BRP OOB w/c amb BR

36. Let’s Practice C/o SOB BR c BRP Ht and wt qod V/s qid D/C in am Amb tid Npo @ hs SSE prn TPR and B/P qd

37. Dealing with Conflict Conflict: a clash between opposing ideas or concepts

38. Dealing with Conflict Conflict Causes: Arguments Unrest Unpleasant work setting

39. Dealing with Conflict Identify the problem Use Problem Solving Techniques

40. Dealing with Conflict • 6 Steps to Problem Solving: • Identify the problem • Collect Information • Identify Possible Solutions About the problem

41. Dealing with Conflict 6 Steps to Problem Solving: 4. Select the best solution 5. Carry out the solution 6. Evaluate the results

42. Communication Listen Talk Privately Be polite Give facts and specific behaviors Offer Solutions

43. Review Which description would have the same meaning for everyone? Hot Warm Elevated temperature Temperature of 99° F

44. Review Which does notpromote communication? Being brief and concise Giving information in the order the events occurred Presenting facts Talking about two subjects at once

45. Review Medical records are legal documents. True False

46. Review The __________________ is a quick easy source of information about the resident. It is a special card that summarizes the resident’s care plan, current diagnosis, routine care, special equipment used and any other special needs. Kardex

47. Review The entry below was made on the wrong chart. Correct the error Voided 300cc clear yellow urine. Error ep

48. Review The center allows you to record on charts. Which is incorrect? Ink is used, not pencil Only center-approved abbreviations are used Errors are erased All entries are signed with your name and title.

49. Review The clock shows 7:29 PM. In 24-hour clock time, this is 1929

50. Review The clock shows 12:00 noon. In 24-hour clock time, this is 1200